issue brief MIDWIFERY CARE & BIRTH CENTERS PUBLISHED MAY 2020

As Mississippians cope with a lack of obstetric services in over half of counties in the state, an increasing number of women desire to have less-medicalized births outside of a typical hospital setting. The number of planned births that occurred outside of a hospital in Mississippi grew by 68 percent between 2007 and 2017 as did births attended by . Midwifery care is being explored across the country as a way to alleviate workforce shortages and offer safe, community-based care in low-risk .

Midwives are trained professionals who help healthy women during , labor and delivery, and after birth. Research indicates that integration of midwifery A BRIEF HISTORY OF MIDWIFERY IN care in a and better access to midwives are associated with higher MISSISSIPPI rates of vaginal delivery, vaginal delivery after prior cesarean (c-section), and

In 1927, more than 3,000 lay midwives as well as lower rates of premature births, low birth-weights, and were documented across Mississippi. The neonatal death. While most births that occur in Mississippi are uncomplicated, just mostly black midwives served white women over two percent of pregnancies and births are managed by midwives annually, and black communities with no access to doctors. Many were recruited and trained and few women have access to safe, non-medicalized birth options. as public health nurses by the Department of Health in response to poor public health Midwives have been instrumental in providing uncomplicated pregnancy- and limited access to . By 1975 related care in previous times of provider shortages and poor birth outcomes in only 217 lay midwives were active. Greater availability of physicians and hospital beds, Mississippi. (See sidebar.) Mississippi is currently experiencing a shortage of improved education about medical care, and obstetric providers; women in forty-six Mississippi counties must drive an hour the availability of Medicaid funds for care or more to see an obstetrician (OBGYN) for prenatal, delivery, and post-partum contributed to a shift from home births to hospital-based, medicalized deliveries. care. From 2015 to 2017 Mississippi had the highest rates of cesarean deliveries, pre-term births, and low birth weight in the nation. In response to similar shortages In response to limited capacity at local hospitals and high and maternal and poor birth outcomes, several states have broadened access to maternity care mortality rates, the Mississippi State through midwives and birth centers for women with uncomplicated pregnancies. Department of Health developed maternal and child health (MCH) clinics during the 1970s. The clinics employed certified nurse-midwives to provide and hospital-based deliveries to low- KEY POINTS income expectant mothers in several counties including Warren, Hinds, Bolivar, ƒ Midwives and birth centers provide a model of maternity care that research Washington, Holmes, and Jackson counties. shows can be appropriate for low-risk pregnancies and deliveries with Nurse midwives practicing in the MCH clinics were trained in partnership with the similar or better outcomes as typical obstetric care with lower healthcare University of Mississippi Medical Center. costs. In 1978 nurse midwives conducted over 5,200 visits and delivered 376 in ƒ Certified Nurse Midwives currently practice in Mississippi hospitals, while Jackson County alone. Certified Professional Midwives and Direct Entry Midwives legally practice unregulated in homes and community settings. There is currently no school of nurse- midwifery in the state, and prenatal care has ƒ Birth centers provide midwifery care and operate independently from not been provided in public health clinics since 2017. hospitals. These providers are currently licensable, but none currently operate in Mississippi. Source: Beck, T. (2019). ; Mississippi State Board of Health. (1973-1983). Annual Reports.

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Center for Mississippi Health Policy � Brief: Birth Centers and Midwifery Care � May 2020

DRAFT COPY-NOT FOR DISTRIBUTION Midwives as Providers of Maternity Care Three types of midwives are known to practice in Mississippi. Certified Nurse Midwives (CNMs or nurse-midwives), 29 of whom are currently licensed to practice and attend over 800 births (or two percent) annually across the state. Doulas, often confused for midwives, act as part of a birth support team and provide non- Other types of midwives in the state include Certified Professional Midwives clinical, emotional support and advocacy for (CPMs) and Direct Entry Midwives (or lay midwives). In Mississippi, CPMs pregnant and laboring women in any setting. and lay midwives practice legally but unregulated, and the number of these practitioners active in the state is unknown. These midwives are available for women who wish to give birth in home-like settings, but no state-level oversight exists.

PERCENTAGE OF BIRTHS ATTENDED BY MIDWIVES TABLE 1. A COMPARISON OF TYPES OF MIDWIVES CURRENTLY PRACTICING IN MISSISSIPPI IN SOUTHEASTERN STATES, 2018

3 3 2 Certified Nurse Certified Professional Direct Entry Midwife Midwife Currently Licensed by State Not currently, but licensed in 35 No 3 Licensable Board of states Percent of all births 2 2 2 L L L MS N Registered nurse National certification* after 3-5 years training with of apprenticeship including at least Source: CDC. (2019). National Center for Health Training None required Statistics. Natality Reports (2016-2018). advanced practice 2 years of clinical education and degree in midwifery observing 55 or more births Primarily hospitals Site of Home and and Home and community settings MINIMUM STANDARDS OF OPERATION FOR Practice Community BIRTHING CENTERS birth centers Mississippi Code 41-77-1 thru 25 authorizes Self-pay; No the licensure and regulation of "birthing Reimbursable Mostly self-pay; reimbursable by known insurance centers" by the State Department of Health. Payment via Medicaid and some commercial insurance plans; coverage; Services are limited to those typical in commercial insurers Medishare uncomplicated and do not include Medishare cesarean section. Labor in birthing centers is allowed to progress without medically Source: The American College of Nurse-Midwives. (2017). * North American Registry of Midwives. (2020). unnecessary intervention.

State Minimum Standards require birthing Nurse midwives practice in all 50 states, and CPMs are licensed to practice centers to be operationally independent from in 37 states including Tennessee, Louisiana, Arkansas, Alabama, and Florida. hospital delivery units. They may operate Lawmakers in Florida have formally recognized the role of midwives in reducing under the direction of a nurse midwife or a , and are required to maintain a a shortage of providers of prenatal and delivery services and have provided for referral agreement with a hospital that has Medicaid reimbursement for CPMs in addition to nurse midwives. an organized obstetrical staff and 24-hour emergency care and cesarean section capability within 30 minutes. Patients stays Birth centers offer another option for uncomplicated deliveries. in birth centers are limited to 24 hours. Birth centers operate according to the midwife model of care and are an option Source: MSDH. (2016) Health Facilities Regulation. for pregnant women at low risk of complications who want a non-medical delivery but not at home. Medicaid and commercial insurers cover birth center services, which have significantly lower costs due to fewer medical interventions and less RISK OF BIRTH INJURY expensive staff. Because midwife-managed care limits intervention and allows for While research reflects decreased risk normal progression of labor, data show the risk of some birth-related injuries is less, of birth injury due to less intervention, although risk of shoulder dystocia may be higher. (See sidebar.) Studies indicate that one study has shown an increased risk of shoulder dystocia associated with midwife- fewer than 10 percent of births initiated in birth centers require transfer to medical manged births among women with two or care during labor. State law requires that birth centers maintain written agreements more previous deliveries. with acute care facilities for transfer of laboring women in case of emergency. Birth Source: Souter, V., et al. (2019). Comparison of centers currently operate in Tennessee, Arkansas, and Louisiana. There are no Midwifery and Obstetric Care in Low-Risk Hospital Births birth centers that meet the state minimum standards currently providing this care in the state. 2 of 4 Center for Mississippi Health Policy � Issue Brief: Birth Centers and Midwifery Care � May 2020

DRAFT COPY-NOT FOR DISTRIBUTION Key Differences in Midwifery Model of Maternity Care Midwives in any setting practice what is known as the Midwifery Model of Care, UNCOMPLICATED DELIVERY An uncomplicated delivery involves a single which views pregnancy and birth as normal, healthy physiologic processes. baby delivered vaginally at full term and Midwives support women throughout pregnancy, delivery, and post-partum positioned head-down. periods. Midwife-managed prenatal care includes pregnancy assessment as well as lifestyle and behavioral interventions, and emotional support. In case of complications at any point in the pregnancy or delivery, women are referred to PRENATAL VISITS a physician's care. Induction, artificially accelerated labor, c-section deliveries, anesthesia, and intensive electronic monitoring are avoided under midwives’ care An average prenatal visit with a physician in a medical setting lasts approximately 15 to but may be provided by medical clinicians as necessary. Midwives may order lab 20 minutes while visits with certified nurse tests and medication as credentials allow and medical necessity requires. midwives in birth centers last at least 30 minutes. Midwifery offers comparable or better outcomes and cost savings. Source: Urban Institute. (2016). Strong Start for Mothers and Newborns. Research shows that in any setting of care, midwife-managed births result in significantly lower rates of induced labor and c-sections which negatively impact , and poor outcomes like pre-term births and low birth weight that endanger infant health. Prenatal and postnatal care are more comprehensive than STRONG START FOR MOTHERS AND NEWBORNS typical medical maternity care and supports improved outcomes like breastfeeding From 2013-2017 the Centers for Medicare and postpartum contraception use, both of which contribute to long-term health of and Medicaid Innovation studied alternate mothers and infants. models of maternity care including birth centers. Birth centers demonstrated better Research also shows that costs improve under a model of care that promotes outcomes compared to the national average for births in all settings including hospitals. minimal intervention and the natural progression of labor and birth via vaginal Some results included: delivery. In 2018, the average total charge to Mississippi Medicaid for an reduced induction of labor uncomplicated cesarean delivery was $27,510 while the average total charge for (16.4% v. 24.5%); reduced primary c-section deliveries an uncomplicated vaginal delivery was $15,854 (inclusive of pre-and postnatal (8.7% v. 21.8%); care and infant care). Approximately 70 percent of Medicaid deliveries billed that increased breastfeeding at discharge year were uncomplicated. (92.9% v. 83.1%); and lower rates of NICU admissions (2.8% v. 8.7%). FIGURE 1. LOW RISK CESAREAN AND VBAC BIRTH RATES IN MISSISSIPPI COMPARED WITH THE U.S., 2013 & 2018. Source: Alliman, et al. (2019). Strong Start in Birth 20 20 Centers. 35 35 3 32 3 3 2 25 25 25 2 2 COST OF CPM CARE FOR ONE YEAR 5 5 33 One year of care including prenatal, 5 home-based delivery, and postpartum 5 5 care, provided by a Certified Professional Midwife costs $3000-$4000 on average. MS S MS S

Source: Hillman, R. (2020). Primary Cesarean aginal Birth after Cesarean BC Source: Maternal Safety Foundation. (2018).

Mississippi may benefit from greater integration of midwifery.

CESAREAN SECTIONS AND RISK Mississippi mothers with low risk for complications deliver via c-section at the C-section is a surgical procedure, and highest rate in the country (Figure 1.). They also attempt vaginal delivery after prior women who undergo them are at increased risk of blood clots, post-partum hemorrhage, c-section at half the national rate. Rates of uncomplicated c-sections can vary infection, internal organ injury, and need for widely across hospital systems (from 15 to 37 percent in Mississippi hospitals) blood transfusion. Subsequent deliveries which suggests clinical practice patterns and limitations on time, staffing, and labor become more risky, too. Risks to newborns include surgical injury and breathing rooms may play a role rather than population-level health risks. Births initiated under problems. midwifery care are very likely to be delivered vaginally (as many as 93 percent of births in one study). Greater utilization of midwifery would reduce unnecessary c-sections, as well as risk to maternal and infant health and costs of care. 3 of 4 Center for Mississippi Health Policy � Issue Brief: Birth Centers and Midwifery Care � May 2020 Discussion The United States is grappling with a host of reversals in decades-long health and MISSISSIPPI MATERNAL AND public health gains in maternal and child health. Avoidable pregnancy-related deaths CHILD HEALTH OUTCOMES and illnesses have increased for all mothers and infants, but especially black women Mississippi has one of the highest and their children. The burden is heaviest among states in the Southeast, including rates of preterm birth and low birth weight infants in the country, Mississippi where obstetric providers are in short supply. It is unlikely that Mississippi particularly among black infants. will attract enough OBGYNs to meet recommended coverage levels in the near future. However, as many states and other highly developed nations have demonstrated in numerous studies, midwifery care is sufficient and beneficial for many pregnancies. The ALLIANCE FOR INNOVATION ON midwifery model of care has been integrated into national and state-level initiatives to MATERNAL HEALTH (AIM) AIM is a federally funded, national reduce perinatal death and illness as well as racial health disparities in maternal and collaboration of healthcare child health. associations working to reduce severe maternal morbidity and mortality through maternal and Use of birth centers and midwifery care in Mississippi has lagged behind other states non-obstetric safety bundles despite existing enabling policies, such as Medicaid reimbursement for nurse-midwives including a reduction in primary and licensure of birth centers. Additional policy options that would foster greater cesarean sections, a key contribution of midwifery. integration of midwifery into the existing maternity care system in Mississippi include:

ƒ Licensure and regulation of Certified Professional Midwives currently practicing without regulation in the state ƒ Promoting collaboration between medical and non-clinical maternity care providers within medical systems, including both midwives and birth centers ƒ Creation of in-state training programs for Certified Nurse Midwives to expand the maternity care workforce for low risk pregnancies

Studies have shown that integration of midwifery in medical settings yields more favorable outcomes for low-risk pregnancies than medical settings that do not include midwifery—even in deliveries that are not ultimately managed by a midwife. Greater inclusion of midwifery would benefit the uncomplicated pregnancies midwives manage as well as relieve strain on obstetric providers to care for high risk pregnancies Sources Stapleton, S., Osborne, C., and Illuzzi, J. (2013). Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery & Women s Health, 58: 3-14. doi:10.1111/jmwh.12003. Vedam, S., Stoll, K., MacDorman, M., Declercq E., Cramer, R., Cheyne,y M. et al. (2018). Mapping integration of midwives across the United States: Imp.act on access, equity, and outcomes. PLoS ONE 13(2): e0192523. Souter, V., Nethery, E., Kopas, M., Wurz, H., Sitcov, K., and Caughey, A. Comparison of Midwifery and Obstetric Care in Low-Risk Hospital Births, & Gynecology: November 2019 - Volume 134 - Issue 5 - p 1056-1065 doi: 10.1097/ AOG.0000000000003521 Alliman, J, Stapleton, S., Wright, J., Bauer, K., Slider, K., Jolles D. (2019). Strong Start in birth centers: Socio-demographic character- istics, care processes, and outcomes for mothers and newborns. Birth. 2019;46:234-243. American College of Nurse-Midwives. Comparison of Certified Nurse-Midwives, Certified Midwives, Certified Professional Midwives Clarifying the Distinctions Among Professional Midwifery Credentials in the US. (2017). https://www.midwife.org/acnm/files/ccLibrary- Files/FILENAME/000000006807/FINAL-ComparisonChart-Oct2017.pdf American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. (2014). Safe prevention of the primary cesarean delivery. Obstetric care consensus no. 1. Am J Obstet Gynecol, 210 (2014). Maternal Safety Foundation. (2018). Mississippi State Dashboard. www.cesareanrates.org Mississippi State Department of Health. (2017). Hospital discharge data cesarean and vaginal deliveries, 2017. North American Registry of Midwives. (2020). Certifed Professional Midwives (CPM) Candidate Information Booklet. http://narm.org/ Plaza Building, Suite 700 pdffiles/CIB.pdf 120 N. Congress Street Centers for Disease Control and Prevention. (2017). Infant Mortality Rates by State. https://www.cdc.gov/nchs/pressroom/sosmap/ infant_mortality_rates/infant_mortality.htm Jackson, MS 39201 Centers for Disease Control and Prevention (CDC). (2019). National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data 2016-2018, on CDC WONDER Online Database. http://wonder.cdc.gov/natality-expanded-current.html The Big Push for Midwives. (2019). Licensure for CPMs: State Chart. http://PushforMidwives.org. Phone 601.709.2133 The Birth Place Lab. (2018). Midwifery Integration State Scoring System Report Card. https://www.birthplacelab.org/how-does-your- Fax 601.709.2134 state-rank/ Urban Institute. (2016). Strong Start for Mothers and Newborns Evaluation: Year 2 Report. https://downloads.cms.gov/files/cmmi/ strongstart-enhancedprenatalcare_evalrptyr2v1.pdf www.mshealthpolicy.com Beck, T. (2019, September). Phone interview. @mshealthpolicy Mississippi State Department of Health. (2016). Minimum Standards of Operation for Birthing Centers. wwww.msdh.state.ms.us. Mississippi State Board of Health. Annual Reports. (1973-1983). Mississippi Department of Archives. Hillman, R. (2020, January). Email interview. 4 of 4 Center for Mississippi Health Policy � Issue Brief: Birth Centers and Midwifery Care � May 2020